What are the recommended treatments for postpartum depression, including the use of antidepressants such as selective serotonin reuptake inhibitors (SSRIs)?

Recommended Treatments for Postpartum Depression

For postpartum depression, selective serotonin reuptake inhibitors (SSRIs) are recommended as first-line pharmacotherapy, with sertraline being the preferred option due to its superior efficacy and safety profile in breastfeeding women. 1

First-Line Pharmacological Treatment

• SSRIs are modestly superior to placebo for treating postpartum depression, with response rates of 59% for sertraline versus 26% for placebo 2
• Sertraline and paroxetine transfer to breast milk in lower concentrations than other antidepressants, making them safer options for breastfeeding mothers 3
• Sertraline should be initiated at 50 mg daily and can be titrated up to a maximum of 200 mg/day based on clinical response 2
• Treatment should continue for at least 4-9 months after a satisfactory response for a first episode of major depression 3

Efficacy and Safety Considerations

• Meta-analysis shows SSRIs may be more effective than placebo in treating postpartum depression, with higher response rates (55% vs 43%) and remission rates (42% vs 27%) 4
• Women with depression onset within 4 weeks of delivery (meeting strict DSM criteria for postpartum depression) show more pronounced improvement with sertraline treatment 2
• Neonates exposed to SSRIs late in the third trimester may develop complications requiring prolonged hospitalization, including respiratory distress, feeding difficulties, and neurological symptoms 5
• For women already on antidepressants during pregnancy, discontinuation during pregnancy shows a significant increase in relapse of major depression compared to those who remained on medication 5

Alternative Medications and Approaches

• If sertraline is not tolerated, citalopram may be considered as an alternative, as some infants who cannot tolerate sertraline or paroxetine may better tolerate citalopram 6
• In 2019, brexanolone became the first FDA-approved drug specifically for treating postpartum depression, with zuranolone more recently approved with a similar mechanism of action 1
• For women with severe postpartum depression, antidepressants show more pronounced benefits compared to placebo 3
• Hormonal therapy with oxytocin has shown efficacy in treating postpartum depression, particularly given the role of endocrine factors in its etiopathogenesis 1

Monitoring and Adverse Effects

• About two-thirds of patients receiving second-generation antidepressants experience at least one adverse effect during treatment, with nausea and vomiting being the most common reasons for discontinuation 3
• Clinicians should monitor for potential adverse effects in breastfed infants, including irritability, poor feeding, and sleep disturbances 3
• SSRIs with 5HT3 antagonism properties, such as paroxetine, may help reduce nausea and vomiting, which could improve medication adherence 7
• If a patient does not have an adequate response to pharmacotherapy within 6-8 weeks, treatment modification is recommended 3

Special Considerations for Breastfeeding

• It is unclear whether SSRI use in breastfeeding mothers causes adverse effects in their infants, but monitoring is essential 3
• Infants exposed to SSRIs through breast milk may exhibit signs including crying, irritability, jitteriness, tremors, feeding difficulty, and sleep disturbance 3
• The decision to use antidepressants during breastfeeding should prioritize the benefits of treating maternal depression against potential risks to the infant 5
• For women reluctant to use pharmacotherapy while breastfeeding, non-pharmacological approaches such as bright light therapy and vagal nerve stimulation may be considered 1

Long-term Treatment

• For patients with recurrent depression, treatment beyond the initial 4-9 months may be beneficial 3
• The risk of relapse is significant if antidepressant treatment is discontinued prematurely, particularly in women with a history of depression 5
• Regular follow-up is essential to assess treatment response, manage adverse effects, and adjust medication dosage as needed 3